A damning report into the events that led to the death of Savita Halappanavar has found that the hospital missed opportunities that could have changed the outcome.

The report by the Health Information and Quality Authority (HIQA), which was published this afternoon (October 9), said there was a failure to recognise Mrs Halappanavar was developing an infection and to act on her deteriorating condition.

The report found a failure to provide the most basic elements of care in her case. The 257-page report found that there were many missed opportunities, which if acted on, might have changed the outcome for her.

For example, HIQA said “following the rupture of her membranes, four-hourly observations including temperature, heart rate, respiration and blood pressure did not appear to have been carried out at the required intervals.

“At the various stages when these observations were carried out, the consultant obstetrician, non-consultant hospital doctors (NCHDs) and midwives/nurses caring for Savita Halappanavar did not appear to act in a timely way in response to the indications of her clinical deterioration,” the report said.

The review was conducted after HIQA was asked by the Health Service Executive to investigate the safety, quality and standards of services provided at University Hospital Galway.

It followed the death of Mrs Halappanavar on October 28, 2012. She died one week after she was admitted to University Hospital Galway when she was 17 weeks' pregnant and miscarrying.

The case provoked widespread controversy with many commentators blaming Ireland’s ban on abortion for Mrs Halappanavar’s death. However, a previous HSE review highlighted that the key issues in the death of Mrs Halappanavar were multiple failures to properly assess and monitor her condition.

Today’s HIQA report also revealed wide variations in clinical care in the 19 public maternity hospitals and units. It stated there is no nationally agreed definition of maternal sepsis and inconsistent recording of it nationally, as well as no centralised approach to reporting maternal morbidity and mortality.

It found that University Hospital Galway did not have effective arrangements to regularly record and monitor her condition and that the management of the delivery of maternity services was not consistent with best practices.

Commenting on the publication of the investigation report, HIQA’s Director of Regulation, Phelim Quinn, said: “The investigation findings reflect a failure in the provision of the most basic elements of patient care to Savita Halappanavar. They identified a failure to recognise that she was developing an infection and then a failure to act on the signs of her clinical deterioration in a timely and appropriate manner. The investigation also identified a number of missed opportunities to intervene in her care which, if they had been acted upon, may have resulted in a different outcome for Savita Halappanavar.”

He added, “Effective care and treatment depends on the regular monitoring and recording of a patient’s clinical observations and recognising their significance, acting appropriately on the findings, escalating concerns and the seamless clinical handover of information relating to each patient within and between clinicians and clinical teams.

“However, during the course of the investigation, it was clear that the hospital did not have effective clinical arrangements in place to ensure that this was done. Our investigation uncovered a series of failures in the management, governance and delivery of maternity services at UHG which were not consistent with best practice,” Mr Quinn said.

HIQA believes that, in order to provide assurances that pregnant women are receiving safe, high quality and reliable care during and after their pregnancy, maternity services must collect, monitor and manage quality and safety performance measures to evaluate the performance of their clinicians and the outcomes for patients.